HomeMy WebLinkAboutMiscellaneous - 115 OLYMPIC LANE 4/30/2018 (2) 115 OLYMPIC LANE
210/106.B-0136..0000.0
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CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit# Q 7c�Z
Plan Approval: Date: Approved by:
Designer: IV C--NGCA-AJp e'—iUG Plan Date-
Conditions:
Water Supply-__ Town Well
Well Permit: Driller:
Well Tests: Chemical Date Pp
A roved
�
Bacteria I Date Approved
Bacteria II Date Approve —
Plumbing Sign-Off: Wiring Sign-Off:
Comments:
Form"U" Approval: ^Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES NO r
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
North Andover MIMAP 115 Olympic Lane December 1, 2016
all�atr'�`
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106 B0138„ ra;
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❑MVPC Bo
Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NA083,
v Interstate
—Major Road Meters Data Sources:The data for this map was produced by Merrimack
'AORTH Valley Planning Commission(MVPC)using data provided by the Town of
- Roads Ot 4North Andover.Additional data provided by the Executive Office of
tip re O Environmental Affairs/MassGIS.The information depicted on this ma is
t r Easements y� •e p
L boundary
y
El Parcels 3 _ for planning purposes only.It may not be adequate for legal bounda
O — - fa definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
Floodplain f' _ 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
100 Year Floodplain �t - » THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
[]500 Year Floodplain * s ^ ♦ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
* o9q+ ,N �� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
1"=48 ft w�°
I/A
i
Commonwealth of Massachusetts [HErA,(
E
City/Town of
System Pumping. Record OV Z 4 2014
r Form 4
OF NUM i H ANUMER
' [
'r" �r'JIEIVT
DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio : Le ig fron�If
, Left/Right rear of house, Left/right side of house Left/
Right side of building, Left/Rigilding, Left/Right rear of building, Under deck
Address '
City/Town State Trp Code
2. System Owner.
Name
i
Address(if different from location)
I
Cityrrown - State o
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
Cesspool(s)3. Type of system
eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes aoo If yes, was it cleaned? ❑ Yes ❑ No;
' 5. Conditio�stem:
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L=LL0Q
re contents were disposed:
Lowell Waste Water
Sig Haule Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1
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7 TOWN OF NORTH ANDOVER
tt; •
,SYSTEM PUMPING RECORD
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)ATE,OF PU�VIPING
QUTITY PUMPED
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EMERGENCY
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HEAVY GREASE ? BAFFLES IN PLACE
f, t� � �,�IR ROOTSLEACHFIELD RUNBACK
EXCESSIVE SOLIDS•` FLOODED
I�ktl'•rv'7 r,�s„,� , ;t,�1' L 'e SOLIDS CARRYOVER— � ,SIN
OTHER (EXPLAIN
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Commonwealth of MassachusettsEO-�Jt�
�City/Town of T 15 2007
System Pumping Record
Form 4 TV JH ANDOVER
1 C�:-a;2Tw1E^1T
DEP has provided this form for use by local Boards of Heforms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address �— L
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
+ Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
M --q—&-7_
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. SystePump By:
� ps&
Name Vehicle License Number
Company
7. Location re content were posed:
Signat of ul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
N _
Commonwealth of Massachusetts
fz City/Town of 71('EIVED
a System Pumping Record OCT 3 0 2009
M.y Sva,�v
Form 4
TOWP2()F N;^RTH ANDOVER
DEP has provided this form for use by local Boards of He Ith.lOther 6ansFfnayrbe u ed, but the
information must be,substantially the same as that provided here. Before using Is orm, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or4ottzer approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hous , Left front oA�of
Right front of house,
Left rear of house, Right rear of house. Left rear of building. Ig rear lding.
Address U L .�
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ZIUD Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location yhe contents were disposed:
.L.S.D Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= City/Town of
W° System Pumping Record RECEIVED
.` Form 4
Noy 15 '!011
DEP has provided this form for use by local Boards of Health. Oth r forms��Vmabe useed,, bu the
information must be substantially the same as that provided here. �li"Iv'r ck with your
local Board of Health to determine the form they use.The System pingcor�=mu ubmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio i e � Ig front of hous eft/Right rear of house, Left/right side of house, Left/
Right side of bui Ing, Left/Rig t ront of building, Left/Right rear of building, Under deck
Address
City/Town \J U\ 6 State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown 70S
Zip Code
Telephone Number
B. Pumping Record
Ps
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
G.L S. Lowell Waste Water
tt 4 c
Sign toe I HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORDD
DATE: R
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: UANTITY PUMPED GALLONS
II
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
i
COMMENTS:
CONTENT � `✓ "
S TRANSFERRED TO:
II
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3' Form No. 4
o
,r Town of North Andover;Massachusetts
t BOARD OF HEALTH
DecemhPr 1 R ,1 9 ()7
CERTIFICATEOF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( x) or repaired ( )
4 :
by _ John Sone. !'
INSTALLER I y
at 115 Olympic Lane, North Andover MA 01845
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No.___27_ dated Nov_ 1 4_ 19 q
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
[BOARD OF HEA TH
I
t
FORM 11 - SOIL EVALUATOR FORM
Page i of 3
No. l oZ Date: /Zq
Commonwealth of Massachusetts
Massachusetts
Foil /Suitability Assessment fo� r On- i, to Sewage Disposal
Performed By: `' ......C-........7�..'` .............................. Date: +�/' ��7._....._.......
WitnessedBy: ..... W14. ,......... .............................................. ............
Loation Address or /IA5— 4-40Ar2-1� Owna•$N...,
{ New construction ❑ Repair Z'
Office Review
I
Published Soil Survey Available: No ❑ Yes
Year Published / �.......... Publication Scale !F Soil Map Unit .-,.__.......
Drainage C1ass/--Pz/-')! � •. Soil Limitations .......... .......... ... . __ ,....._.
Surficial Geologic Report Available: No 0 des ❑
Year Published Publication Scale ...
Geologic Material (Map Unit) ....... ................................................_............_..........._..._
................................................ .................
Landform ....................... . ............................_..�....
.................................................................................................................... ..........................
Flood Insurance Rate Map:
Above 500 year flood boundary No []Yes
Within 500 year flood boundary No ❑Yes ❑ -'
Within 100 year flood boundary No ❑Yes
Wetland Area:
National Wetland Inventory Map (map unit)
.........................................................................................._........
�......
Wetlands Conservancy Program Map(map unit) ..... ......................................._.._..._..........
Current Water Resource Conditions(USGS): Month
Range :Above Normal ❑Normal ❑Belcw Normal Ef
Other References Reviewed:
DEP APPROVED FORM-12/07/9S
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No.
On-site Review
Deep Hole Number ..::.:: .:.. Date:.:: :.:. .: .. 7 Time:.. .:: • Weather
Location (identify on site plant ! ..:.:..::. ,.....:..:.
Land Use Slope {%► ...:.. Surface Stones .
Vegetation
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body���� feet Drainage way ���� feet
Possible Wet Area sem feet Property Dine ...: �� feet
Drinking Water Well feet Other ....:-:
DEEP OBSERVATION HOLE LOG*
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, %
Gravel)
Ot-Z HULE6 KLUUiRLD AT EVERY PROPOSED DISPOSAL AREA
Parent Material(geologic) %'� ��L �l/TI� sR DepthtoBedrock:
Depth to Groundwater: Standing Water in the Hole: l Weeping from Pit Face:
Estimated Seasonal High Ground Water:
DEP APPROVED FORK!-12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No.//`S' mZ`/MP/C
--
On-site Review
Deep Hole Number Z Date:O/�s//7 Time:..--:30 Weather /2
Location (identify on site plan) `� ...
Land Use Slope M Surface Stones
Vegetation
.............
Landform
Position on landscape (sketch on the back) ��
Distances from:
Open Water Body/00' feet Drainage way /:?O feet
Possible Wet Area feet Property Line ..ZS., feet
Drinking Water Well .:..::." feet Other
DEEP OBSERVATION HOLE LOG*
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, %
Gravel)
141
3A
D AT EVERY PROPOSED DISPOSAL ARET
Parent Material(geologic) DepthtoSedrock:
Depth to Groundwater: Standing Water in the Hole: 3 Weeping from Pit Face:
Estimated Seasonal High Ground Water•.
DEP APPROVED FORK!-12/07/95
FORM 11 - SO)!L EVALUATOR FORM .
Page 3 of 3
Location Address or Lot No. /lf� ���I1,Ef -« Na
Detennination r Seasonal Hi h Water T le
Method Used: � AM:
.D.fid. X/v- z
❑ Depth observed standing in observation hole................... inches
Depth weeping from side of observation hole................. inches
❑ Depth to soil mottles ...,,....:..,, inches
❑ Ground water adjustment ................... feet
fhdex Well Number .................. Reading Date ......I.......... Index well level ...................
Adjustment factor ................... Adjusted ground, water level .......................................... . ..
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material? —
Certification
I certify that on (date) I havepassed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature Date
i
DEP APPROVED FORM-12/07/95
Town of North Andover, Massachusetts Form N0.3
t pORTI{,
BOARD OF HEALTH '
O
F . <2U' J 19�
DISPOSAL WORKS CONSTRUCTION PERMIT
HUS
I i
i Applicant_
NAME ADDRESS '
TELEPHONE
Site Location-_ /A—�
i
Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. 979-
CHAIR<^BOARD OF HEALTH i
7 - 931/ +`
Fee — D.W.C. No.
Town of North Andover-,.Massachusetts Form No.2 R:
BOARD OF HEALTH
o t•..e,��ti x
Y 'b;�;�-•�� = �DESIGNAPPROVAL FOR
. T 1^''P'8 .� S ane E q7 uL �+ T " -
14 a, s n,tSOIL' ABSORPTION'SEWAGE DFSPOSALSYSTEM
—
' A � -F r-L..3r.i i�iMR'n'fi,. 2A+.�'•tiwr��-a.�'+'L-»-• -• �.+f� .. ...y ,y {.:i'•.a w�. �— L`
t y`3 w Oryx n a v
1"ww��-nt iu w< rl.•.. 'tr„a.r. SrS�.'•;s 'N� i --,.s_ ! �. ;r
1� ... •-s,,it-� ,...<, ..e.eN ^.s- _ �:{Ifi•sra. wti+'"!` -.:. ay. rray 5.
A"-^'°�"C.�,l�
pp Kest No =
v L y
' �s-a �` °�`' At `t`�--�»-'
(-3taR £.t ..
7� Srte:Location # t —
er
1� Referencpecs Iola
EN !NEER , , `: DES GN ^» �_ ..w
DATE z
°.'•'+r�.s:.w -
WA
Permisslon !s granted fog an Individual soll'�absocptlonswa a d!s oral s stemto:be-installed-
# n accordance with regulatlons`of Board
r ,
a AIRMAN 0 R O
,1 -- ri, A D F HEA
k CH' ,B
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z Fee o- SI Sy
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Town of North Andover, Massachusetts Form No. 1
NORTH A BOARD OF HEALTH l
3�0 1 l bL ` I���•, , sY 19 �.
0 ,i -'E'd F! Re f�
J /
1 y
APPLICATION FOR SITE TESTING/INSPECTION
DRATED PPp�•(y
SSACHUS�
Applicant �� -•
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
�•
Test/Inspection Date and Time ! '�%-��� -/� f��i' / r•'
CHAIRMAN,BOARD OF HEALTH
Fee Test No. f
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
MOITM
BOARD OF HEALTH
-s� 146 MAIN STREET -9540TEL. 688
CHUSE` NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE: z z q-7
LOCATION OF tOlL TESTS: J1,5-
Assessor's
IsAssessor's map & parcel number:
OWNER: Z4 0„ TEL. NO.:
ADDRESS:
�cvv e.�1 -ley;„ce,
ENGINEER: TEL. NO.:
CERTIFIED SOIL EVALUATOR:
v
In7ded use of land: residential subdivision, single family home, commercial
THE LLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of$175.00 per lot for new construction. This covers the two deep holes
and two percolation tests required for each lot. Fee of$75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design
septic plans.
3. At least two deep holes and two percolation tests are required for each septic
system.
4. Repairs require at least two deep holes and at least one percolation test, at
the discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of
testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1”-100') shall be
submitted to the Board of Health showing the location of all tests (including
aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.